PFD report

Samuel Garner · Prevention of Future Deaths report

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Issued 27 Jul 2020•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
17

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Lack of appropriate Emergency Department space for treating vulnerable patients
    Part of recurring concern: Insufficient emergency-department capacity for timely patient carePart of recurring concern: Unsafe emergency-department crowding leaving patients without appropriate clinical space
  2. Lack of surgical bed capacity delaying transfer from the Emergency Department
    Part of recurring concern: Failure to ensure timely transfer to an appropriate hospital care environmentPart of recurring concern: Failure to provide timely hospital admissionPart of recurring concern: Failure to safely coordinate transfer of urgent surgical patients
  3. Delays in performing clinically required chest drainage due to competing staff demands
    Part of recurring concern: Failure to provide timely access to clinically required chest drainagePart of recurring concern: Unreliable chest drain insertion and management
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.17

  1. Action

    Provide additional funding to alleviate Covid-19 winter pressures and support NHS capacity.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 1 October 2020.
  2. Action

    Roll out support for care home residents so more people can receive care in their communities.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 1 October 2020.
  3. Action

    Maintain Nightingale Hospitals and their surge capacity.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 1 October 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Stockport health system partners are responsible for taking action to address urgent and emergency care safety concerns.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of appropriate Emergency Department space for treating vulnerable patients

Wider context from the report

“2. As a result of the lack of appropriate space Mr Garner for an elderly and vulnerable patient was treated in the corridor for periods during his stay in the ED. This included whilst he was being given antibiotics intravenously - he scored on the sepsis pathway on arrival. He was also moved in and out of bays depending on varying prioritisation of need. ”

Is this part of a recurring concern?

Yes — Insufficient emergency-department capacity for timely patient care; Unsafe emergency-department crowding leaving patients without appropriate clinical space.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of surgical bed capacity delaying transfer from the Emergency Department

Wider context from the report

“4. It was identified at an early stage that he would need a surgical bed and his care would be optimised in such a setting. There was a significant delay in moving him from the Emergency Department to a surgical ward due to lack of bed capacity within the Trust. ”

Is this part of a recurring concern?

Yes — Failure to ensure timely transfer to an appropriate hospital care environment; Failure to provide timely hospital admission; Failure to safely coordinate transfer of urgent surgical patients.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in performing clinically required chest drainage due to competing staff demands

Wider context from the report

“3. He waited a number of hours for his chest to be drained (after it was identified that was what was required) due to competing demands on clinical staff. He was in significant distress whilst waiting. ”

Is this part of a recurring concern?

Yes — Failure to provide timely access to clinically required chest drainage; Unreliable chest drain insertion and management.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to maintain sufficient Emergency Department capacity during recurring periods of high demand

Wider context from the report

“1. The inquest heard evidence that on admission to Stepping Hill Hospital the Emergency Department was extremely busy due to the volume of patients in the department. This had been typical of the picture in both the preceding and following weeks due to winter pressures/demands. ”

Is this part of a recurring concern?

Yes — Insufficient emergency-department capacity for timely patient care.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide additional funding to alleviate Covid-19 winter pressures and support NHS capacity.

Verbatim wording from the response

“This year, we have provided an extra £3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS’s use of independent sector hospital capacity.”

Source location

2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Roll out support for care home residents so more people can receive care in their communities.

Verbatim wording from the response

“The NHS Long Term Plan commits funding worth £4.5billion per year by 2023/24 to be focused on primary and community care. This includes a national roll-out of support for care home residents so more people can be looked after where they live. The NHS also aims to place therapy and social work teams at the beginning of the acute hospital pathway, setting an expectation that patients will have an agreed clinical care plan within 14 hours of admission, including an expected date of discharge.”

Source location

2020-0145-Response-from-DHSC_Redacted.pdf
Page 3 · response
Published 1 October 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Maintain Nightingale Hospitals and their surge capacity.

Verbatim wording from the response

“This year, we have provided an extra £3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS’s use of independent sector hospital capacity.”

Source location

2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue implementing Same Day Emergency Care to reduce non-elective hospital admissions.

Verbatim wording from the response

“In 2019/20, this involved continued work to tackle both the increases in demand in urgent and emergency care and to ensure patients receive the quality of care they need and expect in a timely and safe manner. For example, the continued roll out of Urgent Treatment Centres, offering a consistent service to patients and introducing the ability to book appointments through NHS 111, as well as initiatives such as Same Day Emergency Care, to reduce non-elective admissions to hospital.”

Source location

2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue rolling out Urgent Treatment Centres, including appointment booking through NHS 111.

Verbatim wording from the response

“In 2019/20, this involved continued work to tackle both the increases in demand in urgent and emergency care and to ensure patients receive the quality of care they need and expect in a timely and safe manner. For example, the continued roll out of Urgent Treatment Centres, offering a consistent service to patients and introducing the ability to book appointments through NHS 111, as well as initiatives such as Same Day Emergency Care, to reduce non-elective admissions to hospital.”

Source location

2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Introduce NHS 111 First to provide low-complexity digital care and direct patients to appropriate settings more quickly.

Verbatim wording from the response

“Other elements of the NHS winter plan for 2020/21 include ‘NHS 111 First’ which will provide low complexity care digitally and ensure those who need more care can receive it in the right setting more quickly, rather than waiting in A&E².”

Source location

2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide funding to continue enhanced hospital discharge arrangements and maintain safe, timely patient discharge over winter.

Verbatim wording from the response

“This year we made £1.3billion funding available via the NHS to support the hospital discharge process in March. As part of the £3billion funding for winter, an extra £588million has been confirmed to continue enhanced discharge arrangements over winter and maintain the safe and timely discharge of patients from hospital.”

Source location

2020-0145-Response-from-DHSC_Redacted.pdf
Page 3 · response
Published 1 October 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide NHS Long Term Plan funding for primary and community care by 2023/24.

Verbatim wording from the response

“The NHS Long Term Plan commits funding worth £4.5billion per year by 2023/24 to be focused on primary and community care. This includes a national roll-out of support for care home residents so more people can be looked after where they live. The NHS also aims to place therapy and social work teams at the beginning of the acute hospital pathway, setting an expectation that patients will have an agreed clinical care plan within 14 hours of admission, including an expected date of discharge.”

Source location

2020-0145-Response-from-DHSC_Redacted.pdf
Page 3 · response
Published 1 October 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Maintain NHS use of independent-sector hospital capacity.

Verbatim wording from the response

“This year, we have provided an extra £3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS’s use of independent sector hospital capacity.”

Source location

2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement Greater Manchester Discharge to Assess guidance, including standard referral, rapid triage, testing and PPE, medication supply, and next-day follow-up processes.

Verbatim wording from the response

“As part of the initial COVID 19 response, Greater Manchester localities worked to rapidly develop updated Discharge to Assess Pathway Guidance, which were formally approved in late April and have now been adopted across all localities within”

Source location

2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 4 · response
Published 1 October 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Use patient safety checklists in all Greater Manchester acute-trust emergency departments to support timely assessment and reduce risks from corridor care.

Verbatim wording from the response

“It should be noted that all of the acute trusts in Greater Manchester now utilise a patient safety checklist in their Emergency Departments. These checklists are time-based frameworks that outline clinical tasks that need completing for each patient in the first hours of their admittance to an ED. It ensures that assessments and tests happen in a timely way in order to help mitigate some of the risks associated with corridor care. These have been adopted from the national checklist template which was published in 2017 and which has been proven to improve clinical processes and reduce harm and serious incidents from unrecognised patient deterioration.”

Source location

2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 3 · response
Published 1 October 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review community-based capacity to support discharges.

Verbatim wording from the response

“The guidance is fully aligned with national policy and guidance and there has been significant additional community-based capacity created to support this. Whilst we saw some initial improvements from this work, the second COVID wave is adding further pressure on acute hospital beds due to increased admissions and reduced bed availability as a result of infection, prevention control and staffing issues. Further work is underway to review community-based capacity to support discharges and to review elective care activity within hospitals. Reducing or suspending elective care work will help to provide additional capacity for patients, such as Samuel Garner, who have urgent care needs.”

Source location

2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 5 · response
Published 1 October 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue developing the Urgent and Emergency Care Operational Hub’s methods for managing demand and patient flow to reduce emergency department crowding.

Verbatim wording from the response

“It is also worth noting that GMHSCP also has a Greater Manchester Urgent and Emergency Care Operational Hub, which is designed to provide real time support to local systems by monitoring and managing patient flow. The hub has a near to real time data feed from all acute hospital sites, which it uses to support decision making around deflection of ambulances to alternative destinations, when a hospital emergency department is showing signs of pressure. The hub also supports the management of discharges from hospital and repatriations between hospital sites (in and out of the GM area). The hub is under constant development and is working closely with systems to develop more sophisticated methods of managing demand to reduce the likelihood of emergency department crowding even further and proactively managing flow to prevent blockages.”

Source location

2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 3 · response
Published 1 October 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review elective-care activity within hospitals to assess whether capacity can be provided for patients with urgent care needs.

Verbatim wording from the response

“The guidance is fully aligned with national policy and guidance and there has been significant additional community-based capacity created to support this. Whilst we saw some initial improvements from this work, the second COVID wave is adding further pressure on acute hospital beds due to increased admissions and reduced bed availability as a result of infection, prevention control and staffing issues. Further work is underway to review community-based capacity to support discharges and to review elective care activity within hospitals. Reducing or suspending elective care work will help to provide additional capacity for patients, such as Samuel Garner, who have urgent care needs.”

Source location

2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 5 · response
Published 1 October 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Launch a Greater Manchester campaign promoting NHS 111 First before emergency department attendance.

Verbatim wording from the response

“I can confirm that all localities within GM have now gone live during the last 3 weeks with their services. A new national campaign to promote 111 First will be launched in early December which will encourage patients to call 111 before deciding to attend an emergency department.”

Source location

2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 3 · response
Published 1 October 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Create additional community-based capacity to support discharge pathways and improve acute-hospital patient flow.

Verbatim wording from the response

“The guidance is fully aligned with national policy and guidance and there has been significant additional community-based capacity created to support this. Whilst we saw some initial improvements from this work, the second COVID wave is adding further pressure on acute hospital beds due to increased admissions and reduced bed availability as a result of infection, prevention control and staffing issues. Further work is underway to review community-based capacity to support discharges and to review elective care activity within hospitals. Reducing or suspending elective care work will help to provide additional capacity for patients, such as Samuel Garner, who have urgent care needs.”

Source location

2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 5 · response
Published 1 October 2020

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement NHS 111 First and pre-Emergency Department triage and streaming services across Greater Manchester localities.

Verbatim wording from the response

“The onset of the COVID 19 crisis delayed the transformation programme until more recently when we have refreshed our planning work and agreed to rapidly implement new models of care during September and October this year (ahead of winter). The new approach will incorporate two elements:”

Source location

2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 2 · response
Published 1 October 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Stockport health system partners are responsible for taking action to address urgent and emergency care safety concerns.

Verbatim wording from the response

“It is essential that health system partners in Stockport take the necessary action, quickly, to respond to these findings and improve the safety and quality of urgent and emergency services in Stockport.”

Source location

2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The chest drain was inserted within 100 minutes of the decision; delays reflected clinical requirements, not competing staff demands.

Verbatim wording from the response

“Therefore, the decision to insert the chest drain was made at 2030hrs when the ST1 documents the advice from cardiothoracics. The drain had been inserted no more than 100 minutes later. Mr Garner was moved from cubicle 13 to resus bed 2 at 2054hrs which would imply no actual delay, as he needed to be in the right place and such a procedure requires equipment and personnel to be assembled, and then the procedure takes some time. The attending doctor records it to have been an uncomplicated procedure. Oramorph was given at 1823hrs and IV paracetamol after the drain was inserted, and often significant amounts of analgesia are necessary to facilitate the drain insertion, but that was not required. There are multiple nursing entries that do not suggest him to be in pain or discomfort. His oxygen requirement improved dramatically after the drain.”

Source location

2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 4 · response
Published 1 October 2020

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The NHS and local partners, including social services, are responsible for preventing unnecessary hospital discharge delays and arranging ongoing care.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The NHS and local partners, including social services, are responsible for preventing unnecessary hospital discharge delays and arranging ongoing care.

Verbatim wording from the response

“It is the responsibility of the NHS and its local partners, including social service departments, to ensure that no patient remains in a hospital bed for longer than clinically necessary and that any ongoing care and support can begin promptly. Discharge arrangements from hospital should start well before a patient is actually ready for discharge, and the hospital should involve local services at the earliest opportunity to plan post-discharge care and avoid delays.”

Source location

2020-0145-Response-from-DHSC_Redacted.pdf
Page 3 · response
Published 1 October 2020

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026